How can child protection agencies use telehealth to increase service access for children and families?
Telehealth has the potential to offer many children and families a lifeline to essential physical and behavioral health services that would not otherwise be accessible. Although the use of telehealth in child welfare practice has been of interest for many years, particularly in rural areas, more jurisdictions are now expanding its use to support child and family access to critical services during the present COVID-19 crisis — with the potential to carry it forward beyond the pandemic. Telehealth has the potential to:
- Increase access to specialized medical and mental health expertise.
- Ameliorate client transportation and time barriers.
- Enhance staff capacity by reducing travel time in remote areas.
- Increase acceptance of services by some clients who may be more comfortable participating remotely.
- Realize cost savings that may help to offset anticipated post-pandemic budget shortfalls.
Telehealth under COVID-19 has fundamentally changed how we think about treatment. We’re thinking more about the therapeutic benefit of services. Nothing has been sacrificed. If we continue to see better engagement in services, outcomes that are just as good if not better, increased workforce stability, and decreased administrative costs … what an amazing opportunity to take this forward, beyond the present crisis.
– Denise Macerelli, Deputy Director, Office of Behavioral Health, Allegheny County (Pa.) Department of Human Services
More child welfare-specific research is needed, but studies comparing the outcomes of in-person and telehealth for physical and behavioral health care services have generally found that the two approaches can achieve similar results. This strategy brief discusses a variety of uses for telehealth in the child welfare context, provides some key implementation considerations, and offers examples of use in specific jurisdictions. For additional resources, see: Where can child protection leaders learn more about implementing telehealth for behavioral health services?
Telehealth in child welfare
According to the U.S. Substance Abuse and Mental Health Services Administration, telehealth services often are provided in real time through videoconferencing, chat, and text messaging. Telehealth also includes services provided through email, online training, automated computer programs, and mobile apps, or through a client video recording that a professional reviews remotely at another time.
Some examples of how telehealth can be used to support children and families involved with the child welfare system include:
- Using telemedicine technology to conduct remote medical examinations for suspected child abuse and neglect. This approach can make investigations more accurate and timely, and less burdensome for families, when there is no child abuse pediatrician practicing in the area.1
- Conducting standardized behavioral health assessments and remote counseling, monitoring, and medication management.
- Providing “virtual home visits.” Most of the national early childhood home visiting models have endorsed the use of videoconferencing and other technologies during the COVID-19 crisis and provided related guidance.
- Facilitating completion of service plans by offering remote access to some required services, such as parent education, support groups, and substance use disorder treatment.2
- Offering enhanced mental health support to youth in foster care via text or video chat. Given that many youth are comfortable in virtual environments, providing services this way may reduce stigma and enhance engagement.
Some questions to consider for child protection agencies implementing telehealth services are:3
- Does the selected technology effectively address therapeutic goals? As with all aspects of child welfare services, clinical judgment and family-centered practice should drive decisions about assessment and treatment. Denise Macerelli, deputy director of the Allegheny County (Pa.) Department of Human Services’ Office of Behavioral Health, says this is something her agency was cautious about when first allowing providers to offer telepsychiatry: “We wanted to be sure that the rationale made sense in terms of better serving the clients, not just creating an advantage for providers. Throughout the application process, we asked providers a lot of questions about that.”
- How will client safety and confidentiality be protected? During the pandemic, the U.S. Department of Health and Human Services’ Office for Civil Rights announced that health care providers would not be subject to penalties for violations of HIPAA (Health Insurance Portability and Accountability Act) privacy rules that occurred during the good faith provision of telehealth. This opened up opportunities for services to be delivered on a wider variety of non-HIPAA-compliant platforms, including FaceTime, Zoom, and Skype. Privacy and confidentiality are still important considerations, however, bringing forth a range of key questions: How will consent forms be updated to reflect telehealth, and how will client signatures or acknowledgements be obtained? What protocols will be necessary to ensure client privacy at both the provider’s location (e.g.,soundproof work spaces, headphones) and the client’s (e.g., asking who is present, taking care not to bring up sensitive topics if it is unclear whether the client is alone)?
- How prepared are providers to offer telehealth? Agencies will want to consider the technological savviness of providers that will deliver services remotely, and address the following questions: Can they navigate the platform and troubleshoot/resolve simple technology problems quickly and effectively? What training or support will be needed to ensure that providers are confident in their ability to build rapport and maintain a natural conversational flow with children, youth, and families in a virtual environment? Relationships are essential to all child protection-related services. Open communication with providers and among provider agencies also is critical to identify concerns and find solutions.
- How will clients be prepared for telehealth? Clients need access to devices and broadband internet to facilitate smooth audio/video connectivity. In many rural or tribal locations, this is not simply a matter of resources because the telecommunications infrastructure may not support adequate internet speeds. Some agencies have addressed technology challenges by subsidizing enhancements to clients’ internet service plans or providing smartphones if needed. Children and families may need information in advance on how the telehealth service will be delivered and how to set up the technology. Providers should always establish backup communication plans (e.g., telephone) in case a virtual video connection is lost midstream.
- How will the agency adhere to evidence-based practices? Research suggests that some evidence-based practices (for example, Cognitive-Behavioral Therapy and Trauma-Focused Cognitive-Behavioral Therapy) can be delivered effectively using virtual communication.4 The implementation and effectiveness of telehealth, however, will likely vary by model. It is important to review research and/or consult with model developers whenever possible. Tracking outcomes of telehealth approaches is important and will continue to build the body of evidence in this emerging area of child welfare practice.
- How will services be billed? During the pandemic, many Medicaid and private insurance billing guidelines have been relaxed to allow increased billing for telemedicine. Not all states, insurers, and plans, however, allow telehealth services to be billed at parity with in-person visits.
What has helped us make the switch to telehealth? Doing the hard, messy work all along — thoroughly and thoughtfully honoring where we are, adhering to best practices, and prioritizing difficult conversations. We have a level of trust and engagement with our providers that is unparalleled. We work with them intensely and intentionally, year round. The pivot was possible because those relationships were already strong.
– Lisa Hill, Executive Director, Invest in Kids
In Colorado, Invest in Kids is a state-based intermediary for a home visiting model, Nurse-Family Partnership (NFP), and a social and emotional program, Incredible Years (IY). Prior to the COVID-19 crisis, NFP used virtual communication to connect staff across the state, support reflective supervision, and conduct home visits with established clients under specific circumstances (such as inclement weather or a client’s move out of state). In part due to this established foundation, NFP was able to pivot to almost exclusively virtual home visitation quickly after the onset of the pandemic by working closely with model developers and national service offices, expanding on protocols already in place (for HIPAA compliance and client consent), and offering staff training in effective virtual communication techniques. IY staff also have been able to continue established parent groups and support classroom-based social skills lessons via Zoom. All telehealth services have been well received — in fact, NFP enrollment was higher in March 2020 than March 2019 (when introductory meetings were conducted exclusively in person). Invest in Kids is now gathering data that will allow comparison of model fidelity and outcomes for in-person and telehealth services on a variety of measures.
As an urban county with ready access to behavioral health expertise, a breadth of services, and an investment in face-to-face care, Allegheny County has been thoughtful about its approach to implementing telehealth. When the COVID crisis hit, the Office of Behavioral Health had just opened the option of telepsychiatry to address an emerging shortage of psychiatrists. With the onset of the pandemic, previously strict state regulations were relaxed, and providers were encouraged to quickly ramp up additional mental health and substance abuse treatment services via telehealth. Close partnership with provider agencies has been essential, leaders note, and has paid off in a wealth of creative solutions including: immediate access to psychiatrists in hospital emergency rooms and juvenile detention facilities; virtual access to certified recovery specialists; and telehealth monitoring coupled with mobile delivery of medication assisted treatment for opioid addiction. With more ways to engage clients, substance use disorder treatment providers are optimistic that they may see more engagement and longer lengths of stay in outpatient treatment, which are two key indicators for positive outcomes. The county is also hearing anecdotal reports from providers regarding increased staff morale, productivity, and engagement.
In 1998, Florida became the first state to pilot the use of telehealth for expert medical evaluations of child maltreatment allegations. The program currently operates in 17 sites through a hub-and-spoke system that connects specialized child abuse pediatricians in urban areas to surrounding counties where that expertise is lacking. On-site nurses use advanced image capture and other telemedicine equipment to assist the remote doctors in conducting approximately 500 examinations per year. An early evaluation found that families’ concerns about the technology were easily resolved, and that the technology seemed to increase timeliness of decision-making while reducing stress and inconvenience for the child and family.5
1 Arnold, S. & Esernio-Jenssen, D. (2013). Telemedicine: Reducing trauma in evaluating abuse. Retrieved from https://www.intechopen.com/books/telemedicine/telemedicine-reducing-trauma-in-evaluating-abuse.
2 See, for example: Taylor, T.K., Webster-Stratton, C., Feil, E. G., Broadbent, B., Widdop, C. S., & Severson, H. H. (2008). Computer-based intervention with coaching: An example using the Incredible Years Program. Cognitive Behaviour Therapy, 37, 233–246. Retrieved from https://www.tandfonline.com/doi/abs/10.1080/16506070802364511; Reese, R. J., Slone, N. C., Soares, N., & Sprang, R. (2015). Using telepsychology to provide a group parenting program: A preliminary evaluation of effectiveness. Psychological Services, 12(3). 274–282. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25602503; Schamberger, K. (2016, October 27). Addiction treatment organization finds success with online program. KC Digital Drive. Retrieved from https://www.kcdigitaldrive.org/article/addiction-treatment-organization-finds-success-with-online-program/.
3 Information in this brief is based in part on interviews with Denise Macerelli, Jewel Denne, and Dr. Latika Davis-Jones, Allegheny County Department of Human Services’ Office of Behavioral Health; Dennis Watson, Florida Department of Health; and Lisa Hill, Julie Steffen, and Michelle Neal, Invest in Kids.
4 Dent, L., Peters, A., Kerr, P. L., Mochari-Greenberger, H., & Pande, R. L. (2018). Using telehealth to implement cognitive-behavioral therapy. Psychiatric Services. Retrieved from https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201700477; Stewart, R. W., Orengo-Aguayo, R. E., Cohen, J. A., Mannarino, A. P., & de Arellano, M. A. (2017). A pilot study of trauma-focused cognitive–behavioral therapy delivered via telehealth technology. Child Maltreatment, 22(4), 324–333.
5 Pammer, W., et al. (2001). Use of telehealth technology to extend child protection team services. Pediatrics, 108, 584–90.